Karen started having a deep burning sensation with intercourse a few months into her first long-term relationship. Sex had never been comfortable for her but she had a few times when it felt easy and fun. But over years the burning gradually got worse and her fear of it increased until sex and pain became linked in her mind. Sometimes now her boyfriend Jon is unable to penetrate her because her vagina is so tight it feels like it is cramping. Even oral sex and touch have become intolerably painful, although sometimes Karen tries to push through it. Sometimes Jon is understanding, sometimes he is frustrated, but mostly both Jon and Karen are confused. Why is this happening? Why can’t sex be easy like it is for other people? Karen’s gynecologist says there is nothing wrong with her, but the pain is very real.

Sexual pain is rarely talked about but it is not uncommon. The type of pain I described here, called Vestibulodynia, affects some 17% of women in their lives. It can last for many years, even decades, and sadly often goes untreated. Factors such as genetics, hormones, infections, allergies,inflammation, and tiny tears in the tissue can contribute. And there are several other common diseases that can cause sexual pain, adding to the numbers of people suffering a major loss to their sex lives. And there are conditions that cause sexual pain for men as well, equally unspoken.

One incredibly challenging aspect of any chronic pain is the isolation involved. There is no way to measure pain objectively, no one else can truly understand or monitor your pain except for you. This can cause people to question themselves. For sexual pain, every woman I have worked with had been told by a doctor that there was nothing physically wrong, leading to years of self-doubt and distrust that anyone could help. In fact, the people that we generally go to for sexual health questions – our gynecologists – are simply not well informed or trained in sexual functioning issues. Sexual pain is a specialty and practitioners can be hard to find but when you do they can often diagnose and treat disorders that a majority of doctors will miss.

And treating sexual pain includes sex therapy. Not because it is all in your head, as it may have been treated in the past, but because ongoing pain, particularly pain that affects such a valued part of your life as sex, is traumatizing. It can lead you to feel alienated from your body, from pleasure, from your partner, from the universe or god or anyone who didn’t help. It may have reinforced past sexual abuse memories or negative beliefs about sex. You may have stopped seeing yourself as a sexual person. There is grief over what you have lost and about the ongoing worry about if the pain will return. Recovery requires new relaxation skills, new attention to sensation and lots of communication with future partners. Reflexive tightening and anxiety about sex can make things worse so it is important to get support as you prepare to reengage with sex.

I know what an investment couple’s therapy can be and the vulnerability that goes with it. It helps to know what to expect. Here are some things to bear in mind as you consider therapy as a next step.

Know you will have to change – A relationship is a system, self sustaining much of the time. If you want something to change, you had better be ready to change yourself. It can be a comforting fantasy to imagine your partner doing all the changing, after all you have all kinds of good ideas about how they should be different, right? But it really does take two to do whatever it is that you have been doing. So when you get ready to go to couple’s therapy, know that you will be asked to get really interested in your part and what you can and cannot be responsible for.

Prepare to be surprised – Therapy opens up rooms in your life and heart and mind that may have been closed. Your partner will say things that surprise you. This is actually a gift, as we come to remember that our partners are slightly mysterious individuals with a lot going on inside of them that we are not automatically privy to. This can be scary, but also invigorating for a relationship. You will also surprise yourself in therapy with revelations about things you may have casually overlooked for years. Intimacy builds, I believe, through these moments of uncovering and risk, sometimes painful, sometimes incredibly comforting, but more genuine than normal talk around the dinner table.

Plan to make more time for your relationship – It is hard to stay close and interested in each other when you do not spend any focused time together. One therapy session a week will build some new intimacy but if it doesn’t continue at home we are wasting our time. One of the most important things couples can do to make their gains in therapy matter is to be ready to make changes to their schedules. I mean to literally sit down together with their calendars and carve out time to be a couple in relationship, time for talking, time to have fun, time to have sex, and time to relax together. If you are like most couples now, your time has gotten filled up with all kinds of activities of varying importance. To reinvest in your relationship, you are going to have to give some of those other obligations or habits up.

Find a skilled Therapist – If therapy feels like an extra hour a week that you have the same old arguments and leave feeling angry and wounded, then it is time to find a different therapist. Your therapist should be interacting with you, sometimes interrupting you or calling foul, shaking things up, and giving you a new experience or perspective on what has been going on in your relationship. Now, the therapist cannot do that without your help; you have to be willing to do something different. And the best therapist in the world will not be able to make couple’s therapy always fun and heartwarming. But therapy should never feel like more of the same or like a free for all to attack each other. Find a therapist who makes you both feel supported and challenged in balance.

Have an exit plan (and a backslide plan) – Some of the things I talk about with couple’s in therapy are quick fixes; things that can be repaired with some specific changes and then will flow smoothly. But often issues in couples’ therapy will continue to have some residue of hurt for some time. Rebuilding trust takes time. Changing ingrained patterns will take time and have some moments of backsliding. Before you close your couple’s therapy have a conversation about the realities of relationships, giving each other the benefit of the doubt when things are rocky, and what you will each commit to do if or when things start to feel difficult again. Returning to therapy is not a failure, it is a sign that you have the tools in place to be successful long term.

Is your relationship ready for some renewal? Consider a Couple’s Intensive with Melissa Fritchle, LMFT and Sex Therapist. Spend a few days in beautiful Santa Cruz with beach walks at dusk, private therapy sessions during the day, and heart-opening playful “homework” in the evening. You deserve to make your relationship as strong and intimate as it can be!

In yoga communities you may hear a saying attributed to different teachers depending on who you talk to, a reminder to us performance-oriented types. It is : “We don’t use our body to get into the pose, we use the pose to get into our body”. This is an invitation back from striving or pushing to get our nose to our knee. There is no right way, no finish line to cross in the pose, even if your neighbor over there looks like that yoga calendar person. Instead the goal or intention of this practice is to focus on what we feel in our body as we do this and to learn about who we are in this moment at this point in our life. Learning to use the poses, these external structures, to go internal and get curious about our self.

Imagine if we approached sex in this same way. If instead of hitting a minimum of 3 different sex positions, bringing our partner to screaming orgasm, and looking good while we did it, we focused on something more real. What if instead of using our body for sex, we used sex to get into our body? Then “doing it right” would mean you were focused on sensation, aware and conscious of your own responses and emotions, riding each moment as it shifts and changes. You might need to slow down and breathe, like I do in yoga, to not get overwhelmed by intense sensation or comparisons or self doubt, but to surrender into what is happening. You might start to see efforting, worrying, and performing as signs that you are sliding away what is real and gently bring yourself back to how it feels to let your breath gush out, to press against your partner’s skin, to recognize the fluttering heat in your pelvic muscles, to arch your back, to make eye contact, to go faster or nearly stop.

Sex is an opportunity for us to be fully aware. It can show us things about our self if we utilize it in this way. While there is a lot of exciting external stuff going on, our internal experience is pretty amazing too. If doing it a certain way brings you out of yourself and into thinking and planning and trying to excel, you may be missing the gift. There is so much happening in one minute of a sexual encounter, so much detail and wonder and complexity, it is easy to miss it. But how great it can be to let all that richness and information in, to really stay curious and aware. Setting this as a sexual intention doesn’t dictate what kind of sex you have. Like yoga poses, there are many ways to get into your body. As you get better at staying aware, you can experiment endlessly. What in your goal when being sexual with a partner? Is it to feel pleasure, to achieve a release, to connect or show love, to express something about who you are? Any of these will be better achieved if you stay attuned with yourself and move from there.

I know from experience, if I go to yoga wanting to impress someone or prove something to myself, it is probably going to be bad class for me. I may even go home hurting. But if my goal is to listen to myself and be honest about where my mind, body and heart are able to take me that night, I will have the best class possible. The best sex possible for you is the sex that is happening in real-time in your body, mind, and heart. It is worth shifting your perspective so that you can be there for it.

Our first attachments are to our caregivers. This is a unique form of love, with need and safety and deep power differentials, that will impact us our entire life. It is also one of the first relationships were we begin to “practice” with a child’s mind the idea of romance, and its connection to love. Children learn by playing, enacting scenarios and seeing how it feels. This can be empowering even though the play is “not real” as the child imagines that they could handle themselves in that scenario.

It is very common for children around age 4 to 6 to develop crushes on adults in their life, more commonly a parent. This can be an icky and awkward phase for the parent who is the focus of their attention since it feels very inappropriate. Children in this stage may profess their love, get jealous of the parent’s partner, ask for extra attention, and even try to kiss the parent the way they saw in cartoons. For the child’s development though it is entirely appropriate to imagine and pretend and to get information from adult’s responses. It makes sense for a child to try these new possibilities out with someone they love, look up to and feel safe with, so they are actually making a good choice in play partner. It is helpful if adults are calm and kind about this phase (remember it will pass soon enough). Gently saying something like, “I love you too, so much. You are my beautiful little boy. But romantic love, when people get married or kiss passionately or XYZ, happens between two people who are close in age. So I will be with an adult, like me. And you will eventually find someone your age to be with. And you and I get to love each other as mommy and son and that is a really special love”.

What can happen, in large part because most adults have a healthy internal taboo against sex with children, is that adults overreact to a child’s natural style of learning – experimentation and play practice. Children may get shamed or unintentionally scared by an adult’s negative reaction. It is important to set firm boundaries as the adult about how you do and don’t want to be touched and also about the limits of your relationship (as true with children as with other adults, right?). There is no need to scold or punish a child for having their version of a crush, in fact this could cause them to feel uncomfortable or to doubt those feelings when they arise later in life. There is also no need to encourage the feelings and adults should be careful that they are not using the child’s affection to manipulate the child’s behavior or to create triangles or alliances in the family. Just remember that the child is trying on adult roles, not having adult feelings.

This is the same age that many kids will play house, acting out family dynamics, patterns, and habits in ways that can be dismaying or adorable to those being mimicked. Adults are role models, even when we are not aware of it, and children look to us for guidance on how to do this thing called life. They are taught early on, in fairytales and stories, TV shows, and magazine covers in the checkout line, that romantic love is something to be desired. One of the crucial things they seek to learn from us is how to love and be loved. Let’s strive to show them love can be kind, understanding, and unconditional but also with clear boundaries. Not a bad thing to remind ourselves of too.

We hold these truths to be self-evident, that all people are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness – including sexual liberty and happiness.

To be truly sexually independent we…

*Must have available to us accurate information about sexuality, sexual options, and our bodies

*Must be free from employers, politicians, or other people in power denying us the right or ability to decide what to do about our own sexual health

*Should be able to present ourselves, regardless of gender identity, which genitals we have, sexual orientation, age, or other characteristic, in a way that feels genuine and true to us, without fears of discrimination or harassment

* Should be able to talk to professionals who are non-biased and sex-positive and who will support us in making decisions for ourselves

*Should be able to explore our unique paths to sexual pleasure and desire

*Will value our sexual relationship with our self and feel free to give it time and attention

*Need to advocate for and expect privacy and protection in our sexual lives, with an understanding that our sexual history or images of us should not be shared without our consent

*Deserve sexual relationships that are free from coercion, bullying, or shaming

*Have the freedom to create relationship structures and agreements that are right for us and our partners

One of the first sexual interventions a parent makes for a child is the decision to circumcise or not. And, as with many future sexual interventions, the parents may not have the best or most accurate information. We have been seriously misinformed about the foreskin. Many of us grew up thinking it was an unimportant, inconsequential flap of skin. But, generally speaking, our bodies don’t work that way, right? Think about it – how many other body parts do we just figure we can do without?

The foreskin actually has several purposes. First it represents 25-50% of the skin of the penis and is full of nerve endings. The most sensitive nerve endings of the penis are in a ring on the inner foreskin which are stimulated by stretch and movement. The foreskin is a double layer skin system with the inner layer containing glands that produce fluid to keep the penis protected and slippery. The soft internal layer also provides some immune protection with plasma cells, which secrete antibodies, and pathogen-killing enzymes. The foreskin protects the sensitive head of the penis when it is unerect. Without the foreskin the skin of the penis toughens up a bit as it is exposed to more friction through daily life. The foreskin also maintains lubrication and decreases friction during penetrative intercourse by bunching at the opening of the vagina. This could also provide more stimulation of the vulva.

This may be unwelcome information to you, either because you have chosen to circumcise a child or because you yourself were circumcised. But I think it is important to have accurate information about our bodies, including all body parts. There has been confusing information about health risks associated with keeping the foreskin but even in the face of those questions not one world health association actually recommends routine circumcision. In America we are more familiar with the look of a circumcised penis, although that will be changing as our circumcision rates are dropping. The CDC reports that in 2009 68% of US baby boys were not circumcised. Globally the rate of boys left intact is 70 -80%. Religious considerations are a family’s to consider and weigh, but weight them with complete information in mind.

If you are a man who has been circumcised you may feel some grief or anger about this decision that was made for you before you could choose for yourself. You may feel sadness about the unknowns, what might have been with your foreskin intact. It is difficult to compare the experience of a man uncircumcised since birth with a man who was circumcised. The best response is to grieve as you need to and to love your body as it is today. Remember there is much joy and pleasure to be had as you explore what works for you and your body.

I came upon this piece of advice for writers, originally from William Faulkner, and it has stuck with me throughout the month. Its emotional resonance can be quite scary. It sounds like the kind of advice you don’t want to take. And, indeed, it asks a lot of you. But I think it represents a vulnerable truth that applies to intimate relationships.

For writers, this applies on one level to the idea that to create emotional truth and tension, you need to be willing for any character, even the most beloved, to die. It also means you should not rely on tricks or themes that have worked for you before. Don’t write what you want to write, don’t let ego lead; write what is true, what organically needs to happen in the story.

This is just as relevant in sustaining intimate relationships. No, I am not advocating violence against your lovers. Nor am I suggesting that you abandon the people of things you love. But I think to sustain true intimate connection, we have to be willing to let things die or transform. We cannot rely on the old way of doing things. We cannot take anything for granted. The way you had amazing sex 2 years ago may not be working now. The person you got to know 5 years ago is different today.

Sometimes we can hold on and protect something we love so tightly, that we stop taking the risks we need to take to keep it alive. Oh, it might be going through the motions. There can be a kind of deadness or numbness that comes from desperately loving something so much we don’t want to rock the boat. But to be fully vibrantly alive we need to take risks. We need to have the difficult conversations, take the fearful step of hearing a new truth from an old love. We want to have faith in our long term connections and often faith is warranted. But we shouldn’t let that make us lazy or fool ourselves into thinking that all the questions are answered and doubt or confusion or change will never visit again.

Just as writers must stay true to their story, we must stay true to our relationships by being aware that everything can end, that everyone has lights and shadows, that change is inevitable. It is committing to aliveness to stop overreliance on past gifts and to risk whatever needs to be given and received now. It is scary. I have a lot of empathy for the couples I see in therapy who are in that frightening and disorienting stage of needing to kill their darlings, their story of their partner and the way things were going to go, to access something new. But that something new is almost always more alive, more honest, more intimate. Maybe for therapy the quote should be – Kill your darlings, so that you can stay alive to what it here for you now.

My generation came of age during the start of the AIDs crisis and we were taught to fear the consequences of STDs. We sat through school assemblies with spunky speakers in brightly colored oversize T-shirts who told us to ask our partners if they had been tested. They gave us scripts and role plays for asking a partner to wear a condom but little guidance about the conversation about STD testing. But hey, we were responsible kids, not slackers when it came to sex, a lot of us did ask partners for HIV tests and maybe for other STDs as well. But few of us found a way to be comfortable or casual about this conversation.

I just learned about a new app for exactly that conversation. Silly me, of course there’s an app for that! It’s a smart concept. Hula hosts and protects consumers STD information which can be downloaded from your healthcare provider to the site. It provides Yelp type reviews and contact info for testing facilities in your area. But the part that could change people’s dating experiences is that you can give someone a code to visit your profile and verify your STD status. So no more, “yeah, I got tested months ago, no worries”, no more wondering if someone really did get tested or how long ago. If you decide you want to take the step of being fluid bonded (sharing sexual fluids, not safe sex) with someone, you have an easy and effective way to responsibly take that step together.

My hope for something like this app is that it makes checking STD status a normal part of the sexual interaction and dating cycle. People dating now cannot deny the reality of STDs. The CDC estimates that nearly 20 million new sexually transmitted infections occur every year in this country, half among young people ages 15–24. It is a part of the sexual landscape and awareness is part of sexual responsibility. We need to find ways to make this less awkward, to normalize safer sex and the steps to take before deciding to share fluids. Can you imagine a time in which during the sexual buildup of a relationship or a hookup someone says, “U make me hot. txt me your STD profile. J”. Whether this sounds scary or sad or brilliant to you, it is a part of the modern dating reality. Anything we can do to make this conversation easier is important.

Put two things that people rarely talk openly about together – sex and menstruation – and what do you get? A lot of myths, exaggerations, unexamined worries, and questions..and a lot of people not talking about what they are doing. Despite old cultural taboos about the nastiness of menstrual blood, a woman having her period isperfectly viable and healthy sexual partner. Some women suffer considerably while menstruating, for others it is a mild annoyance and they would be happy to engage in sex play during their bleeding time. An overview of all studies done on sexual desire and sexual activity levels and menstrual cycles (up to 1980) found mostly variations. Some studies found peaks at mid-cycle, some pre-menstrually, some during menstruation, post menstruation. (Schreiner-Engel, 1980). So once again, everyone is different. If you or your partner are one of the ones who feel desire during her period, not to worry, you get a thumbs up for all kinds of play.

Not only is sex during menstruation not bad for you, it may have some benefits. Orgasm can be a great way to relieve menstrual cramps and headaches, so that can be a good reason to invite a partner to play with you even while bleeding. Of course is you are feeling shy, orgasms from masturbation work just as well. A really interesting study (Meaddough et al, 2002) found that women who had sex and orgasms during their menstruation were less likely to develop endometriosis than women who rarely had sex during their period. This may have something to do with the uterus’ role during orgasm. Uterine contractions that happen during orgasm actually change direction based on the phase of the menstrual cycle. This is amazing to me. Mid-cycle when a woman is most fertile the uterine contractions pull semen up towards the uterus. But during menstruation the contractions serve to expel material out of the vagina. This can also cause your period to last fewer days as the blood gets expelled more quickly. I find this fascinating fact out in Mary Roach’s Bonk.

Fresh menstrual blood is a normal body fluid and is not going to hurt you. It is fine to get it on thighs, penises, hands, etc. It is even fine to engage in oral sex with someone who is menstruating. Of course, if the woman menstruating is carrying an STD or HIV her menstrual blood can transmit this. So practice safer sex, as always. Otherwise, your main concern is messiness. You can shower first, make gently wiping each other down with warm washcloths part of the play, have sex in the shower (use lube!), or just put down towels or old sheets and clean up after. But there is no need to be afraid of your body or your body’s natural cycles. If you feel desire and you want to act on it, go for it.

Now I know we need to take what the media calls “outrage” with a grain of salt, but I had to look into the outrage people are expressing over Lena Dunham’s choice to show her naked body repeatedly in her show Girls. Indeed people are outraged. They are outraged that Lena Dunham is inviting us to see her perfectly normal, not perfect or digitally perfected, woman’s body. They are outraged that she presents her character as someone whom people find beautiful, sexy and desirable seemingly irregardless of her non-Playboy model status. Not only are they not comfortable with this minor depiction of reality in our entertainment, there are some people who are intimating that Ms Dunham doesn’t have a right to show her body in this way. - This makes me outraged.

One of the major voices in this attack on Lena Dunham and her supposed gall in showing her body is the often offensive Howard Stern. OK, he refers to her as “little fat chick” repeatedly, what did we expect from Howard Stern? We have not come a long way, baby, in relation to people feeling like they can critique women’s bodies. But when he links choosing to watch a show that exposes him to Lena Dunham’s body with “rape” because “I don’t want to see that” we all have taken a turn into deeply disturbing and oppressive territory. And sadly, he is not the only voice out there suggesting that Ms Dunham has somehow overstepped her bounds by appearing naked.

Let’s break this down. Assuming a consensual adult setting, are we willing to entertain the idea that only certain people have a right to show their bodies? In what context – in art, entertainment, porn? What about on beaches? Can someone claim to be offended by a fat person in a bathing suit? Do we need to earn the right to show our body by meeting a certain standard? How far do we take this? Does it only apply to celebrities? Are we suggesting that now artists must meet a weight requirement, that directors agree to only use actors who conform to an established standard? Will we institute a new sort of Hayes code that censors body images rather than morally objectionably content? If the majority prefers to see people of a certain body type should we mandate photo-shopping of all public photos? How many people have to decide that Christina Hendricks’ curves are disgusting rather than hot to draw a line? Would Marilyn Monroe’s pregnant body in Some Like It Hot be sell-able nowadays? Do we no longer make any room for diverse representations of the desirable?

Have we really come to place culturally where a normal body is treated as not fit for the public view? Signs point to yes, at least for one vocal group on the internet. And for the many, many women who feel that their own body flaws are cause for shame and exclude them from owning their own version of sexy. This censorship is already happening internally in every inner voice that says, “I can’t be seen in a bathing suit, We need to keep the lights off so my partner doesn’t see my thighs…” In that case, then I guess Lena Dunham is offering us much more than a chance to see her bare her body in the service of story-telling, she is offering us a much needed reality check.

Melissa Fritchle is the author of The Conscious Sexual Self Workbook and a Holistic Psychotherapist, licensed in California as a Marriage and Family Therapist (Lic#48627). She has a private practice specializing in Sex Therapy and Couples Therapy. She travels far and wide, internationally and on the internet, to spread compassionate, sex positive, diverse, realistic sex education.